Balancing commercial and public interests

Alarge number of randomized clinical trials with important health outcomes are completed each year. Those with favorable findings are typically reported and published rapidly, while the publication of those with unfavorable results is often delayed or given a positive "spin." This observation applies primarily to industry-sponsored trials. Our objectives are to discuss the responsibility of pharmaceutical firms to the public with respect to timely, complete, and unbiased information from all randomized clinical trials and to propose solutions for improvements. We believe that in addition to financial obligations to their shareholders, pharmaceutical companies have social responsibilities to the public and to health care providers. However, private markets do not reward or compel optimal disclosure of drug safety or inferiority information on a voluntary basis.A problem which has not previously been identified relates to non-comparability of drugs. A case report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) illustrates how public interests may be violated due to failure to inform about drug inferiority. The current system for dissemination of relevant medical information could be improved if all involved parties collaborated fully. However, full disclosure of trial results is unlikely when research results are unfavorable to the firm. We conclude that expanded government regulations will be required for a satisfactory solution to the problem.

Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial

OBJECTIVE

The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was a randomized, single-blind clinical trial lasting 18 months that was designed to determine whether long-term exercise and dietary weight loss are more effective, either separately or in combination, than usual care in improving physical function, pain, and mobility in older overweight and obese adults with knee osteoarthritis (OA).

METHODS

Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older, with a body mass index of > or =28 kg/m(2), knee pain, radiographic evidence of knee OA, and self-reported physical disability, were randomized into healthy lifestyle (control), diet only, exercise only, and diet plus exercise groups. The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included weight loss, 6-minute walk distance, stair-climb time, WOMAC pain and stiffness scores, and joint space width.

RESULTS

Of the 316 randomized participants, 252 (80%) completed the study. Adherence was as follows: for healthy lifestyle, 73%; for diet only, 72%; for exercise only, 60%; and for diet plus exercise, 64%. In the diet plus exercise group, significant improvements in self-reported physical function (P < 0.05), 6-minute walk distance (P < 0.05), stair-climb time (P < 0.05), and knee pain (P < 0.05) relative to the healthy lifestyle group were observed. In the exercise group, a significant improvement in the 6-minute walk distance (P < 0.05) was observed. The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures. The weight-loss groups lost significantly (P < 0.05) more body weight (for diet, 4.9%; for diet plus exercise, 5.7%) than did the healthy lifestyle group (1.2%). Finally, changes in joint space width were not different between the groups.

CONCLUSION

The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone.

The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results

Osteoarthritis (OA) of the knee leads to restrictions of physical activity and ability to perform activities of daily living. Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability. The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was developed to test the efficacy of lifestyle behavioral changes on physical function, pain, and disability in obese, sedentary older adults with knee OA. This controlled trial randomized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups: Healthy Lifestyle Control; Dietary Weight Loss; Structured Exercise; or Combined Exercise and Dietary Weight Loss. The weight-loss goal for the diet groups was a 5% loss at 18 months. The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory. Exercise training consisted of aerobic and strength training for 60 minutes, three times per week in a group and home-based setting. The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index. Other measurements included timed stair climb, distance walked in 6 minutes, strength, gait, knee pain, health-related quality of life, knee radiographs, body weight, dietary intake, and cost-effectiveness of the interventions. We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks. The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA.

Conducting research related to treatment of Alzheimer's disease. Ethical issues

Researchers are obligated to protect the rights of study participants. Protecting the rights of patients with Alzheimer's disease (AD) is particularly complicated because of the special needs of this patient population, and the characteristics of developing treatments and technologies. Respecting autonomy and the right to self-determination are complicated by difficulties associated with assuring competence, understanding, and voluntariness in the informed consent process. Protecting patients with AD from harm may be complicated because new treatments have subtle side effects that may be difficult to detect in patients experiencing communication difficulties. Harm to patients with AD also may occur from withholding proven treatments in placebo-controlled trials, and in the use of genetic testing. Issues of justice in the allocation of research dollars and the ability of patients with AD to participate in research are also discussed. By recognizing potential pitfalls, researchers involved in testing new treatments for patients with AD can take proper steps to assure ethical treatment of study participants.

A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease

PURPOSE

To compare the effects of short-term (3 months) and long-term (18 months) involvement in an exercise program on self-reported disability and physical function in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A total of 140 patients with COPD were studied in a randomized, single-blinded clinical trial. Self-reported disability and physical function were assessed using a 21-item questionnaire, a 6-minute walk, timed stair climb, and an overhead task.

RESULTS

At the completion of the trial, participants in the long-term intervention reported 12% less disability than those in the short-term intervention (adjusted mean with 95% confidence interval, 1.53 (1.43-1.63) versus 1.71 (1.61 to 1.81) units, respectively; P=.016), walked 6% farther during 6-minutes (1,815.0 [1,750.4-1,879.6] vs 1,711.5 [1,640.7-1,782.3] feet, respectively), climbed steps 11% faster (11.6 [11.0-12.2] vs 12.9 [12.3-13.5] seconds, respectively), and completed an overhead task 8% faster (46.8 [44.4-49.2] vs 50.4 [47.8-53.0] seconds, respectively) than those in the short-term intervention.

CONCLUSION

An 18 month exercise program results in greater improvements in self-reported disability and physical function in patients with COPD when compared with a 3-month exercise program. As such, long-term exercise should be recommended for all patients with COPD.

The effects of physical and emotional status on adherence to a low-fat dietary pattern in the Women's Health Initiative

OBJECTIVE

To examine whether the effects of physical and emotional status on adherance to a low-fat (20% energy) dietary pattern are mediated by participation in an intervention program (attending sessions and self-monitoring).

DESIGN

The Baron and Kenny mediator model, a series of 4 regression analyses, was used to evaluate whether: a) physical and emotional status predicted program participation, b) program participation predicted dietary adherence, c) physical and emotional status factors predicted dietary adherence, and, ultimately d) the effects of physical and emotional status on dietary adherence were mediated by program participation.

SUBJECTS/SETTING

Data from 13,277 postmenopausal women randomly assigned to the low-fat intervention arm of the Women's Health Initiative Dietary Modification Trial.

INTERVENTION

The nutrition goals for women randomly assigned to the low-fat intervention were to reduce total fat intake to 20% or less of energy from fat and to consume 5 or more fruit/vegetable servings daily and 6 or more grain servings daily.

MAIN OUTCOME MEASURES

Year 1 program participation (degree of attending group sessions and submitting fat scores) and adherence to the low-fat dietary pattern (percent energy from fat) as predicted by baseline physical and emotional status (eight SF-36 Health Survey subscales).

RESULTS

Participating in the dietary intervention program reduced (mediated) the negative effect of poorer mental health on dietary adherence by 15%. Additional findings included that a 10% increase in physical functioning increased session attendance by 0.4% (P<.001) and a 10% increase in mental health predicted a decrease in percent energy from fat of 0.3% (P<.001). Program participation had a marked effect on dietary adherence: a 10% increase in session attendance predicted a 1.2% decrease in percent energy from fat (P<.001).

APPLICATIONS/CONCLUSIONS

Understanding and using instruments to assess the physical and emotional status of a target population will help dietetic professionals promote healthful dietary change and maintenance.

Correlates of sleep behavior among hemodialysis patients. The kidney outcomes prediction and evaluation (KOPE) study

BACKGROUND

Given the importance of sleep to overall physical and mental well-being, we sought to identify the correlates of seven sleep disturbances in a cross-sectional study of a biracial population of male and female patients treated with hemodialysis.

METHODS

Univariate and multivariate analyses of a cohort study of adult patients with end-stage renal disease. Demographic, psychosocial, clinical, and health and physical functioning variables were included.

RESULTS

Waking up during the night (57%) and waking up too early (55%) were the most commonly reported sleep problems. Multivariate analyses consistently indicated that levels of pain, depressive symptoms, and physical functioning were consistently associated with the seven sleep disturbances.

CONCLUSION

Sleep disturbances are common in patients with end-stage renal disease. Physical and mental well-being were consistently related to the seven sleep disturbances.

Gender differences in morbidity and mortality related to depression: a review of the literature

In this review of the existing evidence regarding a gender-specific association of depression with major health outcomes in older adults, we were unable to confirm that relative risk of morbidity and/or mortality due to depression varies with respect to gender. Future researchers may wish to concentrate their efforts in the identification of possible biophysiologic mechanisms underlying the association between depression and a variety of health outcomes.

Ethics in adherence promotion and monitoring

In evaluating and intervening to increase adherence to medical treatments, clinicians and researchers must address ethical issues pertaining to best interest, autonomy, and privacy. "Best interest" refers to the notion that health-care practitioners act in a manner that produces benefits or good outcomes for the patients in their care. "Autonomy" refers to the patient's right to determine whether or not they will accept medical treatment or participate in a clinical study. "Nonmaleficence" refers to the clinician's or researcher's responsibility to "do no harm." "Privacy" refers to the notion that researchers and clinicians promise not to divulge personal information about the patients in their care. Adherence monitoring and promotion pose ethical challenges to researchers and clinicians, which are the topic of this paper. Control Clin Trials 2000;21:241S-247S

Dietary adherence: characteristics and interventions

This paper reviews issues regarding dietary adherence. Issues and barriers unique to dietary adherence, in contrast to adherence to physical activity or medication regimens, are discussed. These include decision making, social and cultural contexts, perceptions and preferences, and environmental barriers. We review factors known to increase adherence in dietary interventions, including education, motivation, behavioral skills, new and modified foods, and supportive interactions. We conclude with directions for future study, such as improved measurement of diet-related behavior and longitudinal, culturally sensitive interventions. Control Clin Trials 2000;21:206S-211S

Measuring adherence to behavioral and medical interventions

Measuring adherence to medical and behavioral interventions is important to clinicians and researchers since inadequate adherence can reduce the effectiveness of an intervention. Unfortunately, there is no gold standard for measuring adherence across health behaviors. Adherence needs to be defined situationally with parameters of acceptable adherence carefully delineated and appropriate to the health behavior being studied. Additionally, measurement methods must be valid, reliable, and sensitive to change; this paper reviews these criteria. Methods used to measure adherence to dietary interventions include 24-hour recalls, food diaries, and food frequency questionnaires. Direct and indirect calorimetry, doubly labeled water, and a variety of self-report methods can be used to measure adherence in physical activity interventions. Adherence to pharmacological interventions is assessed using self-report methods, biochemical measures, medication counts, and the automated pharmacy database review strategy. The strengths and weaknesses of these methods for measuring adherence to dietary, physical activity, and pharmacological interventions are reviewed. Control Clin Trials 2000;21:188S-194S

Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis

OBJECTIVES

To describe the types and frequencies of sleep complaints and the biopsychosocial factors associated with sleep disturbance in a large community sample of older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis (OA).

DESIGN

Baseline analyses of an observational prospective study.

SETTING AND PARTICIPANTS

Participants were 429 men and women aged 65 years and older experiencing knee pain or knee pain with radiographic evidence of OA enrolled in the Observational Arthritis Study in Seniors (OASIS).

MEASUREMENTS

Demographic variables (age, gender, ethnicity, education), health (X-rays of knee rated for OA severity, medical conditions, medication use, smoking status, body mass index, self-rated health), physical functioning (self-rated physical functioning, physical performance), knee pain, and psychosocial functioning (social support, depression) were measured.

RESULTS

Problems with sleep onset, sleep maintenance, and early morning awakenings occurred at least weekly among 31%, 81%, and 51% of participants, respectively. Bivariate correlates of greater sleep disturbance in those with OA were less education, cardiovascular disease, more arthritic joints, poorer self-rated health, poorer physical functioning, poorer physical performance, knee pain, depression, and less social support. In regression analyses, each set of variables representing the domains of health, physical functioning, pain, and psychosocial functioning contributed to the prediction of sleep disturbance beyond the demographic set. Finally, in a simultaneous model, white race (trend, P = .06), poorer self-rated health, poorer physical functioning, and depressive symptoms were predictive of sleep disturbance.

CONCLUSIONS

Sleep disturbance is common in older adults experiencing knee pain or knee pain with radiographic evidence of OA and is best understood through the consideration of demographic, physical health, physical functioning, pain, and psychosocial variables. Interventions that take into account the multidetermined nature of sleep disturbance in knee pain or knee OA are most likely to be successful.

Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis

PURPOSE

The purpose of this study was to determine, in a randomized clinical trial of 439 individuals with knee osteoarthritis, the incremental cost-effectiveness of aerobic versus weight resistance training, compared with an education control intervention.

METHODS

Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education. Effect at 18 months was measured using several variables, including: self-reported disability score, 6-min walking distance, stair climb, lifting and carrying task, car task, and measures of pain frequency and pain intensity on ambulation and transfer.

RESULTS

The total cost of the educational intervention was $343.98 per participant. The aerobic exercise intervention cost $323.55 per participant, and the resistance training intervention cost $325.20 per participant. On all but two of the outcome variables, the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group.

CONCLUSION

The data obtained from this study suggest that, compared with an education control, resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function. However, the magnitude of the difference in efficiency between the two approaches is small.

Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults: results of project ACTIVE

BACKGROUND

Project ACTIVE was a randomized clinical trial comparing two physical activity interventions, lifestyle and traditional structured exercise. The two interventions were evaluated and compared in terms of cost effectiveness and ability to enhance physical activity among sedentary adults.

DESIGN

This was a randomized clinical trial.

SETTING/ PARTICIPANTS

The study included 235 sedentary but healthy community-dwelling adults.

INTERVENTION

A center-based lifestyle intervention that consisted of behavioral skills training was compared to a structured exercise intervention that included supervised, center-based exercise.

MAIN OUTCOME MEASURES

The main outcome measures of interest included cost, cardiorespiratory fitness, and physical activity.

RESULTS

Both interventions were effective in increasing physical activity and fitness. At 6 months, the costs of the lifestyle and structured interventions were, respectively, $46.53 and $190.24 per participant per month. At 24 months these costs were $17.15 and $49.31 per participant per month. At both 6 months and 24 months, the lifestyle intervention was more cost-effective than the structured intervention for most outcomes measures.

CONCLUSIONS

A behaviorally-based lifestyle intervention approach in which participants are taught behavioral skills to increase their physical activity by integrating moderate-intensity physical activity into their daily lives is more cost-effective than a structured exercise program in improving physical activity and cardiorespiratory health. This study represents one of the first attempts to compare the efficiency of intervention alternatives for improving physical activity among healthy, sedentary adults.

Cost-effectiveness analysis methods for the REACT Study

The Reconditioning Exercise and Chronic Obstructive Pulmonary Disease Trial (REACT) is a two-arm randomized clinical trial designed to compare short-term versus long-term exercise intervention in terms of physical function, acute exacerbation of chronic obstructive pulmonary disease, health-related quality of life, and cost-effectiveness. Clinical trials such as REACT are now routinely paired with economic analyses, and nurses can expect to play a growing role in the conduct of these studies. This article describes a model that is useful for structuring economic evaluations of health care interventions, and illustrates a cost-effectiveness analysis that is being conducted in conjunction with the REACT study. An in-depth description of collection methods and procedures is provided, as well as a summary of recruitment and retention experience to date.

Cost-benefit of a nursing telephone intervention to reduce preterm and low-birthweight births in an African American clinic population

BACKGROUND

A cost-benefit analysis was performed to estimate the cost-savings obtained from a nursing telephone intervention delivered to pregnant women identified as being at risk for preterm or low-birthweight births.

METHODS

After being screened for eligibility, a total of 1,554 women receiving prenatal care in a clinic located in Winston-Salem, North Carolina were randomized to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse one or two times each week from the 24th through the 37th week of gestation.

RESULTS

No clinical benefits were realized by Caucasian participants. The intervention reduced preterm and low-birthweight births, and resulted in cost savings, for African-American mothers ages 19 and over. No significant differences were seen in the rates of low-birthweight or preterm births and no cost savings were realized from intervention with women ages 18 and younger.

CONCLUSIONS

A prenatal nursing support intervention in a clinic population of pregnant African American women was cost-beneficial for these adults (< or =19 years of age).

Challenges faced in recruiting patients from primary care practices into a physical activity intervention trial. Activity Counseling Trial Research Group

BACKGROUND

Special challenges are encountered when clinical trial recruitment targets a physician practice-based population, as opposed to recruiting from the community. Since most published information about recruitment has focused on the latter group, summation of successful primary-care-based recruitment strategies could prove useful for future trials recruiting from this population.

METHODS

The Activity Counseling Trial (ACT) is a multicenter, randomized clinical trial that evaluated approaches to primary care-based interventions to increase physical activity in sedentary adults 35-75 years of age. Fifty-four clinicians from eight practices recruited 874 participants from three U.S. sites. Recruitment challenges that related, in great part, to the primary care setting included: (1) focusing on patients from ACT physician practices who had regularly scheduled or intend-to-schedule appointments within the next year; (2) placing trial staff in the clinical offices for recruitment purposes; and (3) placing trial interventionists in the physicians' offices. Other challenges were related to recruitment of minorities and men.

RESULTS

Patient mailing yielded 43.4% of all randomized participants, followed by office-based questionnaires (32.5%) and direct telephone contact (21.6%). Based on a retrospective cost-effective analysis (indirect costs excluded), the self-administered office-based questionnaire was the least costly strategy for one site ($14/randomized participant), followed by patient mailing at another site ($58). The direct telephone contact method utilized at one site serving primarily a minority population yielded a per randomized participant cost of $80.

CONCLUSIONS

Recruitment of clinical trial participants from practice-based populations requires modification of the strategies used to recruit from the community. Multiple strategies should be employed, followed closely for their respective yields, and adapted as needed.

Measurement of continuous ambulatory peritoneal dialysis prescription adherence using a novel approach

OBJECTIVE

The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription.

DESIGN

A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time.

SETTING

Patients were recruited from an outpatient dialysis center.

PARTICIPANTS

A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston-Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate.

MEASURES

Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened.

RESULTS

One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent (p = 0.015).

CONCLUSIONS

This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach.

Costs and benefits of respiratory syncytial virus immunoglobulin to prevent hospitalization for lower respiratory tract illness in very low birth weight infants

BACKGROUND

Respiratory syncytial virus immunoglobulin intravenous (RSV-IGIV) has been shown to reduce the risk of lower respiratory illness (LRI) hospitalization in preterm infants and infants with bronchopulmonary dysplasia (BPD). The purpose of this analysis was to estimate the economic costs and benefits of prophylaxis with RSV-IGIV in these groups.

METHODS

The analysis was performed from a payer's perspective and therefore included only costs and cost savings that would be realized by an insurer. Estimates of the direct costs of prophylaxis and the risk and cost of LRI hospitalization were based on data about preterm very low birth weight infants cared for at our medical center. Estimates of the reduction in risk of LRI hospitalization associated with RSV-IGIV were based on data from a randomized trial (the PREVENT Study).

RESULTS

The range of cost for a five-dose course of RSV-IGIV was estimated to be $3280 to $8800 for infants weighing 1.2 to 10.0 kg at the time of the initial dose. Risks of LRI hospitalization were estimated to be 12, 17 and 28%, respectively, for preterm infants without BPD, with mild BPD and with moderate to severe BPD. Estimates of duration and per diem cost of LRI hospitalizations were, respectively, 5 days and $971. The estimated net cost of prophylaxis per infant ranged between $5415 for a 6-kg infant without BPD to $1689 for an infant with BPD and age < or =3 months.

CONCLUSIONS

The cost of RSV-IGIV typically exceeds the cost of hospitalizations prevented by several thousand dollars. Cost minus benefit is lower for infants with BPD and infants 3 months of age or younger.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics

PURPOSE

The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline.

METHODS

KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported.

RESULTS

KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria.

CONCLUSIONS

KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Health-related physical function and quality of well-being prior to and following cardiomyoplasty. A preliminary report

OBJECTIVE

The purpose of this study was to obtain preliminary data regarding the effects of cardiomyoplasty on health-related physical function and quality of well-being.

EXPERIMENTAL DESIGN

Quasi-experimental with repeated measures. Patients were interviewed prior to surgery, with post-surgical follow-up interviews at 6 weeks, 6 months, and 12 months.

SETTING

Interviews were usually conducted by telephone with patients who were at home at the time of data collection.

PATIENTS OR PARTICIPANTS

Four patients receiving cardiomyoplasty at Allegheny General Hospital in Pittsburgh, Pennsylvania.

INTERVENTIONS

Patients received cardiomyoplasty between November 1992 and April 1993. Cardiomyoplasty using the right latissimus dorsi muscle was performed on the first patient. A left muscle-wrap was performed on the subsequent three patients.

MEASURES

Self-reported function and well-being were measured using the Sickness Impact Profile (SIP), the Quality of Well-Being Scale (QWB), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36).

RESULTS

Patient responses on the SF-36 demonstrated general improvement in cardiomyoplasty survivors. Results on the QWB and SIP are mixed.

CONCLUSIONS

Due to the small, incomplete sample and lack of any comparison group, extreme caution must be used in drawing any clinical conclusions from this preliminary data. Future randomized clinical trials of cardiomyoplasty need to include quality of life and health-related physical function as dependent variables. Further psychometric study is necessary which compares the usefulness of these various methods for assessing the value of outcomes for patients with end-stage heart disease.

A confirmatory factor analysis of the Caregiving Appraisal Scale for caregivers of home-based ventilator-assisted individuals

OBJECTIVE

To confirm the underlying dimensions of the Caregiving Appraisal Scale (CAS) with use of data collected from caregivers of home-based ventilator-assisted individuals (VAIs).

DESIGN

Cross-sectional survey.

SETTING

Residences of home-based VAIs.

SAMPLE

Two hundred seventy-seven primary family caregivers of VAIs.

MEASURES

Twenty-eight-item CAS developed by Lawton et al. (1989), and an investigator-developed instrument to assess physical health and sociodemographic characteristics of both VAIs and their caregivers.

INTERVENTION

None.

ANALYSIS

Confirmatory factor analysis with principal components extraction. An oblique (oblimin) solution was used for rotation of the factor matrices. The number of common factors needed to obtain the best fit of the factor model was determined with use of maximum-likelihood estimation. Confirmatory factor analysis with linear structural equation modeling was also performed.

RESULTS

Confirmatory factor analysis did not fully replicate the factor structure proposed by Lawton et al.

CONCLUSIONS

The model proposed by Lawton et al. provides a useful foundation for examining the appraisal of family caregivers of home-based VAIs. Additional development work is needed for the CAS.

Cost-utility of lung transplantation: a pilot study

BACKGROUND

The purpose of this study was to conduct a pilot investigation of the cost-utility of lung transplantation. With this study we provide a threshold analysis to estimate the survival gains that must be achieved for lung transplantation to be considered a beneficial use of society's resources.

METHODS

A cross-sectional cohort design was used. All patients having undergone lung transplantation at the University of Pittsburgh Medical Center between March 1 and August 31, 1994, were identified via roster of transplant recipients (n = 20). Surviving patients were interviewed, by telephone, at their 1-year anniversary date. Utility was assessed by use of the quality of well-being scale. Direct cost of care was estimated from adjusted charges for the surgical admission, plus physician fees per the Medicare Physician Fee Schedule.

RESULTS

The mean quality of well-being score for this group was 0.54 +/- 0.198 SD (median = 0.599, range 0 to 0.728). Summing the physician cost and the adjusted charges for the inpatient operative admission, the average cost of lung transplantation was $153,921 +/- $133,981 SD (median $94,324, range $63,405 to $598,482). At a cost of $94,324 and a utility of 0.599, the survival gain from surgery must be 2.7 years for the cost of the procedure to be justified from a societal perspective.

CONCLUSIONS

Because of the many limitations in this pilot study, no firm policy implication may be drawn from these data. Directions for future research are discussed.

Economic value of caregiver effort in maintaining long-term ventilator-assisted individuals at home

OBJECTIVE

To estimate the economic value of caregivers' efforts in maintaining ventilator-assisted individuals at home.

DESIGN

Nonexperimental, cross-sectional survey.

SETTING

Households of home-based ventilator-assisted individuals residing in 37 states.

PARTICIPANTS

Caregivers of 1404 ventilator-assisted individuals; 277 (19.7%) responses were received.

OUTCOME MEASURES

The Home Ventilator Care Cost and Utilization Survey and the Modified Katz Index.

METHODS

The economic value of caregiver effort was estimated deterministically by opportunity cost, aggregated market value, and aggregated replacement cost and estimated stochastically by ordinary least squares regression. Cost of formal home care services was estimated with the Medicare Schedule of Limits for Home Health Agency Costs. Estimates of total cost of home care for each method of valuing caregiver effort were calculated by summing the cost of formal home care services with the value of caregiver effort.

RESULTS

The average monthly cost of formal home care services was estimated to be $6411 (SD, $8490; median, $2006; range, $0 to $38,607). After adding various values of caregiver effort to the cost of formal home care services, the average cost of home care increases by $960 to $12,483, depending on the method used to calculate the value of the caregiver's time; the median total cost of home care increased by $1403 to $17,793. Data also showed that, depending on the figure used to estimate the cost of long-term care and which method was used to calculate caregiver value, home care was more expensive for at least 4.6% of ventilator-assisted individuals and for as many as 36.7%.

CONCLUSIONS

The incorporation of the caregiver's time value into cost estimates did not substantially reduce the proportion of patients for whom home care was the least expensive alternative, except when caregiver effort was valued at a registered nurse's wage rate. However, the methods used to place an economic value on caregiver effort did not take into consideration the long-term economic impact on caregivers who reduce their work hours or forego employment or educational opportunities, nor did they take into account the lost wages of the ventilator-assisted individual or the extent to which the caregiver was financially dependent on the ventilator-assisted individual.